Northside Hospital

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact the Privacy Official by dialing the main facility number at (727) 521-4411.

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made.
Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a
plan for future care or treatment, and billing-related information. This notice applies to all of the
records of your care generated by the facility, whether made by facility personnel, agents of the facility,
or your personal doctor. Your personal doctor may have different policies or notices regarding the
doctors use and disclosure of your health information created in the doctors office or clinic.

Our Responsibilities
We are required by law to maintain the privacy of your health information, provide you a description of
our privacy practices, and to notify you following a breach of unsecured protected health information.
We will abide by the terms of this notice.

Uses and Disclosures

How we may use and disclose Health Information about you.

The following categories describe examples of the way we use and disclose health information:

For Treatment: We may use health information about you to provide you treatment or services.
We may disclose health information about you to doctors, nurses, technicians, medical students, or other
facility personnel who are involved in taking care of you at the facility. For example: a doctor treating
you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.
Different departments of the facility also may share health information about you in order to coordinate
the different things you may need, such as prescriptions, lab work, meals, and x-rays.

We may also provide your physician or a subsequent healthcare provider with copies of various reports
that should assist him or her in treating you once youre discharged from this facility.

For Payment: We may use and disclose health information about your treatment and services
to bill and collect payment from you, your insurance company or a third party payer. For example, we may
need to give your insurance company information about your surgery so they will pay us or reimburse you
for the treatment. We may also tell your health plan about treatment you are going to receive to
determine whether your plan will cover it.

For Health Care Operations: Members of the medical staff and/or quality improvement team
may use information in your health record to assess the care and outcomes in your case and others like
it. The results will then be used to continually improve the quality of care for all patients we serve.
For example, we may combine health information about many patients to evaluate the need for new services
or treatment. We may disclose information to doctors, nurses, and other students for educational
purposes. And we may combine health information we have with that of other facilities to see where
we can make improvements. We may remove information that identifies you from this set of health
information to protect your privacy.

Fundraising: We may contact you to raise funds for the facility; however, you have the
right to elect not to receive such communications.

We may also use and disclose health information:

To remind you that you have an appointment for medical care;

To assess your satisfaction with our services;

To tell you about possible treatment alternatives;

To tell you about health–related benefits or services;

For population based activities relating to improving health or reducing health care costs;

For conducting training programs or reviewing competence of health care professionals; and

To a Medicaid eligibility database and the Children’s Health Insurance Program eligibility database, as applicable.

Business Associates: There are some services provided in our organization through contracts
with business associates. Examples include physician services in the emergency department and radiology,
certain laboratory tests, and a copy service we use when making copies of your health record. When
these services are contracted, we may disclose your health information to our business associates so
that they can perform the job weve asked them to do and bill you or your third-party payer for services
rendered. To protect your health information, however, business associates are required by federal law
to appropriately safeguard your information.

Directory: We may include certain limited information about you in the facility directory
while you are a patient at the facility. The information may include your name, location in the facility,
your general condition (e.g., good, fair) and your religious affiliation. This information may be provided
to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
If you would like to opt out of being in the facility directory please request the Opt Out Form from the
admission staff or Facility Privacy Official.

Individuals Involved in Your Care or Payment for Your Care and/or Notification Purposes:
We may release health information about you to a friend or family member who is involved in your medical
care or who helps pay for your care or to notify, or assist in the notification of (including identifying
or locating), a family member, your personal representative, or another person responsible for your care
of your location and general condition. In addition, we may disclose health information about you to an
entity assisting in a disaster relief effort in order to assist with the provision of this notice.

Research: The use of health information is important to develop new knowledge and
improve medical care. We may use or disclose health information for research studies but only when
they meet all federal and state requirements to protect your privacy (such as using only de-identified
data whenever possible). You may also be contacted to participate in a research study.

Future Communications: We may communicate to you via newsletters, mail outs or
other means regarding treatment options, health related information, disease-management programs,
wellness programs, research projects, or other community based initiatives or activities our facility
is participating in.

Organized Health Care Arrangement: This facility and its medical staff members have
organized and are presenting you this document as a joint notice. Information will be shared as
necessary to carry out treatment, payment and health care operations. Physicians and caregivers may
have access to protected health information in their offices to assist in reviewing past treatment
as it may affect treatment at the time.

Affiliated Covered Entity: Protected health information will be made available to
facility personnel at local affiliated facilities as necessary to carry out treatment, payment
and health care operations. Caregivers at other facilities may have access to protected health
information at their locations to assist in reviewing past treatment information as it may
affect treatment at this time. Please contact the Facility Privacy Official for further information
on the specific sites included in this affiliated covered entity.

Health Information Exchange/Regional Health Information Organization: Federal and
state laws may permit us to participate in organizations with other healthcare providers, insurers,
and/or other health care industry participants and their subcontractors in order for these
individuals and entities to share your health information with one another to accomplish goals
that may include but not be limited to: improving the accuracy and increasing the availability
of your health records; decreasing the time needed to access your information; aggregating and
comparing your information for quality improvement purposes; and such other purposes as may be
permitted by law.

As required by law. We may disclose information when required to do so by law.

As permitted by law, we may also use and disclose health information for the
following types of entities, including but not limited to:

Food and Drug Administration

Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability

Correctional Institutions

Workers Compensation Agents

Organ and Tissue Donation Organizations

Military Command Authorities

Health Oversight Agencies

Funeral Directors and Coroners

National Security and Intelligence Agencies

Protective Services for the President and Others

A person or persons able to prevent or lessen a serious threat to health or safety

Law Enforcement: We may disclose health information to a law enforcement official for
purposes such as providing limited information to locate a missing person or report a crime.

For Judicial or Administrative Proceedings: We may disclose protected health
information as permitted by law in connection with judicial or administrative proceedings, such
as in response to a court order, search warrant or subpoena.

Authorization Required: We must obtain your written authorization in order to
use or disclose psychotherapy notes, use or disclose your protected health information for
marketing purposes, or to sell your protected health information.

State-Specific Requirements: Many states have requirements for reporting including
population-based activities relating to improving health or reducing health care costs.
Some states have separate privacy laws that may apply additional legal requirements. If
the state privacy laws are more stringent than federal privacy laws, the state law
preempts the federal law.

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or
facility that compiled it, you have the Right to:

Inspect and Copy: You have the right to inspect and obtain a copy of
the health information that may be used to make decisions about your care. Usually, this
includes medical and billing records, but does not include psychotherapy notes. We may
deny your request to inspect and copy in certain very limited circumstances. If you are
denied access to health information, you may request that the denial be reviewed. Another
licensed health care professional chosen by the facility will review your request and the
denial. The person conducting the review will not be the person who denied your request.
We will comply with the outcome of the review.

Amend:If you feel that health information we have about you is
incorrect or incomplete, you may ask us to amend the information. You have the right to
request an amendment for as long as the information is kept by or for the facility. Any
request for an amendment must be sent in writing to the Facility Privacy Official.
We may deny your request for an amendment and if this occurs, you will be notified of the
reason for the denial.

An Accounting of Disclosures: You have the right to request an accounting
of disclosures. This is a list of certain disclosures we make of your health information
for purposes other than treatment, payment or health care operations where an
authorization was not required.

Request Restrictions: You have the right to request a restriction or
limitation on the health information we use or disclose about you for treatment, payment
or health care operations. You also have the right to request a limit on the health
information we disclose about you to someone who is involved in your care or the payment
for your care, like a family member or friend. For example, you could ask that we not
use or disclose information about a surgery you had. Any request for a restriction must
be sent in writing to the Facility Privacy Official.

We are required to agree to your request only if 1) except as otherwise
required by law, the disclosure is to your health plan and the purpose is related to payment
or health care operations (and not treatment purposes), and 2) your information
pertains solely to health care services for which you have paid in full. For other
requests, we are not required to agree. If we do agree, we will comply with your
request unless the information is needed to provide you emergency treatment.

Request Confidential Communications: You have the right to request
that we communicate with you about medical matters in a certain way or at a certain location.
For example, you may ask that we contact you at work instead of your home. The facility
will grant reasonable requests for confidential communications at alternative locations
and/or via alternative means only if the request is submitted in writing and the written
request includes a mailing address where the individual will receive bills for services
rendered by the facility and related correspondence regarding payment for services. Please
realize, we reserve the right to contact you by other means and at other locations if
you fail to respond to any communication from us that requires a response. We will
notify you in accordance with your original request prior to attempting to contact you by
other means or at another location.

A Paper Copy of This Notice: You have the right to a paper copy
of this notice. You may ask us to give you a copy of this notice at any time. Even
if you have agreed to receive this notice electronically, you are still entitled to a
paper copy of this notice.

If the facility has a website you may print or view a copy of the notice by clicking
on the Notice of Privacy Practices link.

To exercise any of your rights, please obtain the required forms from the Privacy Official
and submit your request in writing.

CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised or changed notice will be effective
for information we already have about you as well as any information we receive in the future.
The current notice will be posted in the facility and on our website and include the effective
date. In addition, each time you register at or are admitted to the facility for treatment or
health care services as an inpatient or outpatient, we will offer you a copy of the current
notice in effect.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the facility
by following the process outlined in the facility’s Patient Rights documentation. You may
also file a complaint with the Secretary of the Department of Health and Human Services.
All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that
apply to us will be made only with your written authorization. If you provide us permission
to use or disclose health information about you, you may revoke that authorization, in writing,
at any time. If you revoke your authorization, we will no longer use or disclose health
information about you for the reasons covered by your written authorization. You understand
that we are unable to take back any disclosures we have already made with your authorization,
and that we are required to retain our records of the care that we provided to you.

FACILITY PRIVACY OFFICIAL: Please dial the telephone number below and ask for the facility privacy official.